It was mid-2001; I was in my fifth year of medical school and starting my O&G rotation. I was excited – it was my first time on the labour ward, and I’d never seen a baby born. My allocation was with an experienced, serious but kind midwife, who took me under her wing. I spent (what felt like many) hours with the labouring mother; touching her belly, palpating contractions, taking fetal heart rates and maternal temperatures, and smelling her pads.

The birth neared and Dr S attended. When the baby started to come out, I saw a scrotum and gasped, “It’s the wrong way around!”

“No dear,” said the midwife, “it’s the other way around.”

No fuss, no nonsense, just “the other way around.”

Jump forward to mid-2003, and I was on my first day in labour ward as an intern in Adelaide. It was a Tuesday, and Dr W was the consultant. A woman came into labour with her second child. The baby was breech and they were organising a caesarean birth.

Dr W said, “Follow me, we’re doing a caesarean.”

I traipsed behind, “But why does she need it?”

Dr W turned around and said to me, “Because there was a trial done recently, ‘The Term Breech Trial’. In one arm, there were 1041 women who were breech and meant to have a caesarean. In the other, there were 1042 women who were breech and meant to have a vaginal birth. When they compared them, 1.5% of babies born by caesarean died or were unwell, compared with 5% in the other group. That is why we are doing a caesarean. Because good evidence guides our practice,” he said.

That was vaguely familiar. The day after I had witnessed my first ever birth, Dr S had told me I was very lucky.

“You’ll probably never see another breech birth in your career. Even if you do O&G.” She had pointed me to an article on the labour ward tearoom table; the so-called “Term Breech Trial (TBT)”.¹ I read it then. I didn’t understand it. I forgot about it. This time, after watching the caesarean birth, I read it and tried to understand it.So began my journey to becoming an advocate for and supporter of vaginal breech birth, in a career that began in its entirety after the TBT.

We’ve all seen the following graph – a brilliant visual representation of how quickly the caesarean section rate for breech (and overall) went up, as the vaginal birth rate for breech went down.

Fig. 1. Reitberg, C, Elferink-Stinkens, PM, Visser, GHA. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants. BJOG. 2005;112:205-209. https://doi.org/10.1111/j.1471-0528.2004.00317(opens in new tab).

This data is from the Netherlands, and a representation of more than 35,000 breech births over five years, from 1998 to 2002. Reitberg et al reported that the caesarean rate for breech increased from 50% to 80%.² The trend was evident globally. In Australia, the caesarean birth rate for breech went up from 76.6% to 96.3% in the first 10 years.³ In 2006, the year I started training, 53% of final year trainees reported feeling confident with vaginal breech birth, but only 11% reported intention to offer planned vaginal breech birth as a specialist.⁴ I would hazard a guess it is far less now. In South Australia, where I work, vaginal breech birth rates continue to drop. In 2023, 2.4% of all breech presentations were delivered vaginally in SA, constituting only 0.1% of all births, still lower compared with 0.30-0.4% in 2017.⁵

Within 10 years, entire cohorts of O&G trainees never saw or were taught how to plan for a term vaginal breech birth. It became part of emergency training only, despite data from the two-year follow-up to the TBT showing no difference in the major outcome measures with respect to death and neurodevelopmental delay.⁶ Dr Henry Murray’s article “Term Breech Trial” in O&G Magazine in 2012 is an excellent summary of the concerns the TBT posed to those experienced clinicians and institutions who in Australia and the world at the time provided safe breech birth.⁷ This included the John Hunter Hospital in NSW, who published in 2014 outcomes of their already established breech service.⁸ In this cohort, there were no perinatal deaths, the vaginal birth success rate was 58%, and differences in short term serious neonatal and maternal morbidity were not significant. Multiple (including larger) studies across the world, from that time and since, report similar reassuring outcomes in carefully selected planned vaginal breech birth.^9-16

As my years in training progressed, I found myself lucky to be there when a vaginal breech birth occurred, or I found a way to watch and learn when one was occurring. I sought out my experienced colleagues who could explain to me how to assist a breech birth if necessary and show me on birthing models. I attended usual hospital training, all of which taught the management of breech birth as an emergency. Each time I diagnosed a breech in labour, I advocated for a “wait and see” approach where appropriate. I very quickly learned – as the midwife had said during the first birth I attended – it really was just “the other way around.”

In 2012, I attended a course called Hands off the Breech. This later became known as Become a Breech Expert (BaBE), provided by Dr Andrew Bisits and his colleagues. It was an eye opener to me. All the teaching I’d attended until then had taught management of the breech as an emergency response, not as a normal process.

The following year, I attended a course called The Birth Masterclass, provided by Associate Professor John Svigos AM, Dr Henry Murray, and Professor Steve Robson. This class taught how to plan and manage three skills that were fast becoming directed toward caesarean birth: vaginal breech birth, vaginal birth of twins, and persistent occipital posterior position at full dilatation. The Masterclass (as it became known) ran nationally and in South Australia annually until 2018. I attended every course until I became one of the facilitators and a teacher of breech birth. The course still has relevance, and I am proud to say that it was re-introduced at the 2025 RANZCOG ASM (with additional relevant teaching) to great success.

So how does one support term vaginal breech birth?

No matter how many studies are published suggesting a caesarean is safer or preferred for particular circumstances, someone in that position may still want a vaginal birth. How can we support a fully informed, safe choice for them?

• Know the statistics in absolute terms, not only relative. It may not matter to your patient if something is 10x higher risk than something else if the absolute risk, in their opinion, is low.
• Counsel all options:
  • Talk about the risk relative to a vaginal cephalic birth. The person you are counselling was most likely anticipating a vaginal cephalic birth before discovering the baby was breech. Counsel what their risk of a vaginal breech birth is compared to this, not only compared to a caesarean.
  • The only person who can decide if a risk is too high for them is the birthing parent, and they deserve to know the absolute risks of each option.
• Counsel positively:
  • Start with explaining that there is a choice in birth options for a breech baby – caesarean or vaginal birth. Follow with the considerations that make that pregnancy more or less suitable for each option.
  • Know a list of safe parameters for vaginal breech birth.
• Educate and expose yourself to breech birth:
  • Seek out colleagues who can teach you how to assist one.
  • Seek out courses to practise breech birth.
• Know and practise the manoeuvres that assist birth if it is not progressing smoothly.
• If you cannot provide the service of a vaginal breech birth, there will be somewhere that does. Don’t be afraid to say, “I can’t provide this and I’m sorry, but I know somewhere that can.”

Currently, it is generally considered that the perinatal mortality rate for someone undergoing a planned CS at 39 weeks is about 0.05%, but as high as 0.14%.^16,17 For a vaginal cephalic birth, quoted numbers are under 0.1% (0.01-0.08%). For a planned vaginal breech birth, in a carefully selected person, the perinatal mortality rate can be quoted as under 1% (0.2-0.6%).^{16, 17} There is also evidence for no difference in outcomes for planned vaginal breech birth in nulliparous compared with multiparous people.¹⁸

RANZCOG supports an option to offer vaginal breech birth, with our College statement quoting breech birth “may be a safe for carefully selected women who are counselled appropriately, who birth in facilities with clear guidelines, access to skilled staff, operating theatres and neonatal care.”¹⁹

I agree. When we listen to what our birthing patients need to experience a safe and fulfilling birth and combine that with a safe plan and trust in our training, vaginal breech birth is possible, safe, and evidence-based.